Additional Screenings in the Adult Well Male Examination

to the editor: This review of the adult well male examination discussed the prevention of cardiovascular disease, but did not mention screening of the heart itself. Shouldn’t family physicians be looking for occult or asymptomatic conditions, such as ventricular hypertrophy, ischemic disease, valvular malformations, dysrhythmias, and prolonged QT interval? Please provide guidance about which populations should be screened with electrocardiography, chest radiography, echocardiography, or other studies to detect cardiovascular diseases before they become symptomatic.

Similarly, there was no discussion of the importance of vision examinations in older men to diagnose conditions such as glaucoma, cataracts, macular degeneration, and corneal dystrophy, which would require referral to an ophthalmologist.

in reply: The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to support screening for ventricular hypertrophy and ischemic heart disease using electrocardiography1 or nontraditional risk factors such as coronary artery calcification score.2 Neither the USPSTF guidelines nor any other evidence-based guideline suggests screening for valvular disease, dysrhythmias, and prolongation of the QT interval in asymptomatic patients.

The American Heart Association estimates the theoretical cost of mass cardiovascular screening in athletes to be $2 billion per year, with a cost of $330,000 to detect a single case of relevant cardiac disease.3 If one in 10 athletes with asymptomatic cardiac disease is at increased risk for sudden death without treatment, then the cost of preventing each theoretical death would be $3.4 million.3

Regarding whether to routinely screen older men for glaucoma, cataracts, macular degeneration, and corneal dystrophy, the USPSTF states that current evidence is insufficient to assess the balance of benefits and harms of screening for visual impairment in older adults.4 Based on expert consensus, the American Academy of Ophthalmology recommends a comprehensive medical eye examination for all asymptomatic adults without risk factors for medical eye disease; screening should occur every five to 10 years in patients younger than 40 years, every two to four years in those 40 to 54 years of age, every one to three years in those 55 to 64 years of age, and every one to two years in those 65 years and older.5

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.